Introduction: Despite treatment with antibiotic therapy, spontaneous bacterial peritonitis (SBP) accounts for approximately 20–40% mortality in hospitalized patients. The data is scarce regarding mortality predictors in SBP. Recently, multiple factors have been studied for effectiveness in prognosis prediction in SBP. Therefore, in this study, our main objective was to evaluate the mortality predictors in SBP. Materials and methods: This prospective observational study was conducted at the Department of Hepatogastroenterology, from January 2022 to June 2023. All the patients aged between 18 and 65 years having decompensated chronic liver disease and diagnosed with SBP were enrolled in the study. The excluded population comprised of those who were on hemodialysis, those having history of any solid organ malignancy or transplantation or patients suffering from infections such as those caused by human immunodeficiency virus (HIV) or infections other than SBP. These patients were followed during the hospital stay and after the discharge monthly for 3 months and then at 6 months to assess mortality. Results: A total of 142 cirrhotic patients having SBP were enrolled in the study. Among them, most of them were males [98 (69%)]. Viral hepatitis (65.4%) was the most common cause of cirrhosis in studied population. On univariate analysis, serum total leukocyte count (TLC), international normalized ratio (INR), ascitic TLC, ascitic neutrophils, ascitic lactate, ascitic LDH, CTP score, MELD-Na were significantly higher while serum albumin was significantly lower in the patients who died as compared to those who survived. However, on multivariate cox regression analysis, high serum TLC (p = 0.013), ascitic fluid lactate (p < 0.001) along with high CTP (p = 0.041) and MELD-Na score (p = 0.037) at presentation were the factors that were identified as an independent poor prognostic factors in SBP population. Conclusion: Cirrhotic patients with SBP are at increased risk of mortality. In our study we observed that high prognostic scores such as CTP and MELD-Na at presentation along with increased white blood cell counts and high ascitic fluid lactate levels at presentation are the potential and reliable predictors of mortality in SBP patients.

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is an important entity in patients with type-2 diabetes (T2D). Exploring the prevalence and related factors of MASLD is vital toward developing effective methods of diagnosis and treatment. The objective of this study was to determine the prevalence of MASLD in persons with obesity and T2D. Materials and methods: This cross-sectional study was conducted at a private healthcare facility (Medicell Clinics) in Karachi, Pakistan, reviewing records from January to December 2022. Persons of either gender aged 18 or above with a diagnosis of T2D and/or obesity were analyzed. Results: Of a total of 646 persons, 430 (66.6%) were females. The mean age was 48.58 ± 13.88 years, ranging between 18 and 85 years. T2D was noted in 351 (54.3%) patients, while obesity was observed in 593 (91.8%) persons, 396 (61.3%) had MASLD. Persons having MASLD had significantly higher body mass index (31.16 ± 5.13 vs 28.14 ± 4.76 kg/m², p < 0.001). Likewise, obesity was significantly associated with MASLD (94.9 vs 86.8%, p < 0.001). The odds ratios (OR) and 95% confidence intervals (CIs) are reported in multivariate logistic regression table. Persons with T2DM (OR = 1.519, p = 0.009), and obesity (OR = 2.651, p = 0.001) showed significantly increased odds of having MASLD. The analysis revealed that individuals in the age-group of 18–40 (OR = 1.627, p = 0.014) had increased odds of having MASLD. Conclusion: The prevalence of MASLD was very high in persons with T2D, and obesity. Type-2 diabetes with or without obesity, or the other way around, significantly increases the risk of MASLD. Therefore, these persons should be screened for MASLD to improve clinical outcomes in the affected people.

Background: The purpose of the present study was to evaluate clinicopathological characteristics, patterns of recurrence, survival outcomes, and implications for the addition of chemoradiotherapy for patients with resected perihilar and intrahepatic cholangiocarcinoma (CCA). Materials and methods: For the present retrospective study, we identified 38 and 10 patients with resected perihilar and intrahepatic CCA. In perihilar CCA, adjuvant treatment was given as chemotherapy (n = 13) or chemoradiotherapy (n = 10). In intrahepatic CCA, neoadjuvant treatment was given with transarterial chemoembolization (TACE, n = 1) or chemotherapy plus stereotactic body radiation therapy (SBRT, n = 1), and adjuvant treatment was given to 7 patients with chemotherapy or chemoradiotherapy. Results: In perihilar CCA, preoperative biliary drainage procedures were performed in 27 out of 30 patients with jaundice. The adjacent liver showed secondary sclerosing cholangitis (n = 5) and fibrosis (n = 19). Locoregional recurrence involved the hepaticojejunostomy anastomotic site and lymph nodes. In intrahepatic CCA, the adjacent liver revealed cirrhosis (n = 1), secondary sclerosing cholangitis (n = 1), and fibrosis (n = 6). The sites of recurrence were in the remnant liver and lymph nodes (n = 6). In perihilar CCA, the median overall survival (OS) and disease-free survival (DFS) rates were 30.1 months (95% CI: 22.9–37.4) and 15.1 months (95% CI: 9.74–20.5), respectively. The 2-year and 3-year OS were 60.5% and 44.7%, respectively. Multivariate analysis revealed a significant association of no adjuvant treatment with decreased DFS (p = 0.004), HR 4.03 (95% CI: 1.57–10.4). Recurrence showed an unfavorable association with OS (p = 0.056), HR 2.90 (95% CI: 0.98–8.66). In intrahepatic CCA, the median OS and DFS rates were 41.2 months (95% CI: 13.5–68.9) and 10.8 months (95% CI: 1.98–19.6), respectively. The 2-year and 3-year OS were 66.7% and 53.3%, respectively. The patient with multiple intrahepatic CCA lesions and treated with neoadjuvant chemotherapy and SBRT showed partial pathological necrosis after resection and was disease-free at 3.5 years. Conclusions: The present study showed the effectiveness of the combination of chemoradiotherapy with resection in improving locoregional disease control and survival in patients with perihilar and intrahepatic CCA.

Background: There is an international consensus among experts advocating for the classification of fatty liver disease as a metabolic condition. However, some authors have raised concerns that this metabolic-centric framing may result in the underdiagnosis of metabolicdysfunction-associated steatotic liver disease (MASLD) in lean individuals. The present study was carried out with the objective of describing metabolic characteristics in MASLD and the prevalence of lean MASLD in the general population. Methods: We carried out a hospital-based cross-sectional study. A pre-tested proforma was used to collect data on socio-demographic factors, lifestyle factors, and medical history. Transient elastography and blood investigations were carried out in all patients. The identification of independent predictors for MASLD and liver fibrosis was carried out using multivariable logistic regression. A test of interaction was conducted for studying effect modification in the association of diabetes and MASLD by subgroups of body mass index (BMI). Results: A total of 1,243 participants were interviewed and screened for MASLD. The overall prevalence of MASLD was 43.7% (n = 543), with the prevalence of lean MASLD being 4.3% (n = 53). The prevalence of MASLD in lean vs non-lean subjects differed (21.3 vs 66.7%, p < 0.001). Of the total MASLD cases, lean MASLD constituted 9.7% of cases. The association of diabetes and MASLD did not differ in subgroups by BMI. The test for interaction to detect effect modification was not statistically significant (p = 0.673). Conclusion: The results support laying emphasis on metabolic dysfunction as a key criterion when defining fatty liver disease. The findings emphasize the shared metabolic underpinnings between lean and non-lean MASLD and advocate for inclusive approaches in diagnosis, management, and public health initiatives.

Hepatitis B infection remains a significant global health concern, with hepatitis D co-infection observed in approximately 5% of the patients. Treatment options for hepatitis D are currently limited, with most therapies awaiting approval by the FDA. However, there is a lack of comprehensive data on the prevalence and clinical presentation of patients with hepatitis B and D coinfection, particularly in Pakistan. In this study, we aimed to compare demographic characteristics, clinical presentations, laboratory, and endoscopic parameters along with the different treatment options between patients with hepatitis B monoinfection and those with hepatitis B and D coinfection.

Introduction: Chronic liver disease (CLD) can have a significant impact on the nutritional status of patients. Malnutrition is an under-recognized condition in patients with cirrhosis. Malnutrition increases the incidence and severity of decompensation, increases the risk of infections, and increases mortality. The present study aimed to assess osteosarcopenia and frailty in patients with CLD. Materials and methods: This prospective cross-sectional study included 151 cases of CLD, aged between 18 and 85 years. Anthropometric measurements were performed. Sarcopenia was assessed by handgrip strength using a hand-held dynamometer. Bone mineral density was measured with the help of an office-based DEXA scan (Osteosys). Liver frailty was assessed through performance-based tests. Results: Out of 151 patients, 98 were male (69.5%); mean age was 51.8 ± 13.2. The presarcopenia was seen in 91 (60%) patients, and sarcopenia in 45(30%). Osteopenia was present in 75 (50%) and osteoporosis in 24 (16%). The patients with osteopenia and osteoporosis had a high liver frailty index (LFI) (p-value < 0.001). A significant correlation between body mass index, waist circumference, LFI, calcium level, bilirubin and Child Pugh scores was seen with T and Z scores. Factors associated with low bone mineral density included increasing age and LFI, low calcium and higher PTH. Conclusion: There is a high prevalence of pre-sarcopenia, sarcopenia, osteopenia, osteoporosis and high frailty in our patients with CLD. Early detection and timely intervention in these conditions are important to reduce the associated consequences. All patients with CLD should be assessed for osteosarcopenia and frailty, both at baseline and longitudinally.

Objectives: To predict and characterize the three-dimensional (3D) structure of protein arginine methyltransferase 2 (PRMT2) using homology modeling, besides, the identification of potent inhibitors for enhanced comprehension of the biological function of this protein arginine methyltransferase (PRMT) family protein in carcinogenesis. Materials and methods: An in silico method was employed to predict and characterize the three-dimensional structure. The bulk of PRMTs in the PDB shares just a structurally conserved catalytic core domain. Consequently, it was determined that ligand compounds may be the source of co-crystallized complexes containing additional PRMTs. Possible PRMT2 inhibitor compounds are found by using S-adenosyl methionine (SAM), a methyl group donor, as a positive control. Results: Protein arginine methyltransferases are associated with a range of physiological processes, including as splicing, proliferation, regulation of the cell cycle, differentiation, and signaling of DNA damage. These functional capacities are also related to carcinogenesis and metastasis-several forms of PRMT have been cited in the literature. These include PRMT-1, PRMT-2, and PRMT-5. Among these, the role of PRMT-2 has been shown in breast cancer and hepatocellular carcinoma. To gain more insights into the role of PRMT2 in cancer pathogenesis, we opted to characterize tertiary structure utilizing an in silico approach. The majority of PRMTs in the PDB have a structurally conserved catalytic core domain. Thus, ligand compounds were identified as a possible source of co-crystallized complexes of other PRMTs. The SAM, a methyl group donor, is used as a positive control in order to identify potential inhibitor compounds of PRMT2 by the virtual screening method. We hypothesized that an inhibitor for other PRMTs could alter PRMT2 activities. Out of 45 inhibitor compounds, we ultimately identified three potential inhibitor compounds based on the results of the pharmacokinetics and binding affinity studies. These compounds are identified as 3BQ (PubChem CID: 77620540), 6DX (PubChem CID: 124222721), and TDU (PubChem CID: 53346504). Their binding affinities are −8.5 kcal/mol, −8.1 kcal/mol, and −8.8 kcal/mol, respectively. These compounds will be further investigated to determine the binding stability and compactness using molecular dynamics simulations on a 100 ns time scale. In vitro and in vivo studies may be conducted with these three compounds, and we think that focusing on them might lead to the creation of a PRMT2 inhibitor. Conclusion: Three strong inhibitory compounds that were non-carcinogenic also have drug-like properties. By using desirable parameters in root mean square deviation (RMSD), root mean square fluctuation (RMSF), radius of gyration (Rg), solvent accessible surface area (SASA), molecular surface area (MolSA), and intermolecular hydrogen bonding, complexes verified structural stability and compactness over the 100 ns time frame.

Background: The strong association between type 2 diabetes mellitus (T2DM) and fatty liver is well known, and its nomenclature has even recently changed to metabolic dysfunction-associated steatotic liver disease (MASLD). Healthy MASLD patients are frequently overlooked and maltreated, especially in Bangladesh. In this present study, we tried to correlate T2DM burden in apparently healthy, incidentally diagnosed fatty liver patients on ultrasound. Materials and methods: This cross-sectional study was done in Sheikh Hasina Medical College Hospital, Tangail, Bangladesh, from August 2022 to February 2023. A total of 92 patients with ultrasonological evidence of grade II fatty change in the liver were included and evaluated. Known T2DM, hypothyroidism, consumption of alcohol, HBV or HCV infection, Wilson's disease, autoimmune liver disease, hemochromatosis, and any other chronic liver or kidney disease patients were excluded. The patients were then assessed for the presence and absence of T2DM using OGTT (2 hours 75 gm glucose ≥ 11.1 mmol/L) and/or HbA1c (≥6.5%) as diagnostic criteria. Data was analyzed by SPSS, version 23. Results: Out of 92 patients, 48 were male and 44 were female. A total of 50 patients (54.3%) were newly diagnosed with T2DM. Statistically significant differences were seen in the T2DM group and non-DM group for AST (50.33 IU vs 36.53 IU) and TG (270 mg/dL vs 189 mg/dL). Although no noteworthy differences were evident in mean age (41 years vs 38 years), ALT (58.9 IU vs 60.23 IU), and BMI (28.85 vs 29.29). Conclusions: In the present study, more than 54% of patients with grade II fatty liver were newly diagnosed with T2DM. They would later present with more advanced T2DM and related complications. Although a larger study is needed, physicians and healthcare workers in Bangladesh should be more concerned about treating MASLD patients with early diagnosis of T2DM, recommending prompt lifestyle interventions, and prescribing drugs if necessary.

Introduction: One of the main causes of primary hepatocellular carcinoma and chronic hepatitis is the hepatitis C virus (HCV), with significant variability in its genotypes affecting pathogenicity and treatment outcomes. In India, prevalence ranges from 0.5 to 1.5%, with certain regions showing higher rates. Diagnostic methods include serological and molecular assays, with the HCV core antigen (HCV cAg) assay emerging as a cost-effective substitute for HCV RT-PCR testing. Materials and methods: This study enrolled 292 suspected hepatitis cases from May 2019 to May 2020 in a North Indian tertiary care institute. Demographic, biochemical, and clinical data were collected. Seroprevalence was determined using Qualisa^TM HCV ELISA. Sixty seronegative and 30 seropositive samples underwent HCVc-Ag testing and HCV RT-PCR. Genotyping was carried out using AmpliSens® HCV-genotype PCR kit. The HCV core antigen assay was evaluated by taking HCV RT-PCR as the gold standard test. Results: Of the 292 patients, 98 (30%) were seropositive for HCV, predominantly in the 40–59 age-group. Surgery and blood transfusion were significant risk factors. Co-infections included human immunodeficiency virus (HIV) (3.06%) and hepatitis B virus (HBV) (6.12%). Genotype 3a was the most prevalent. HCV core antigen assay showed 93.75% sensitivity, 93.10% specificity, 88.24% positive predictive value, 96.43% negative predictive value, and 93.33% accuracy. Conclusion: Hepatitis C virus core antigen is a dependable and economical substitute to HCV RT-PCR for diagnosing HCV infection. Regular screening in high-risk groups is essential for early detection and prevention.

Introduction: Chronic pancreatitis is a severe, ongoing inflammation of the pancreas, characterized by significant abdominal pain and deficiencies in both exocrine and endocrine functions. This condition greatly reduces overall well-being, induces psychological distress, and results in a considerable economic burden. The primary indication for surgical intervention is uncontrollable pain. Frey's procedure is the preferred surgical option. Objectives: This research aims to assess the effectiveness of long-term pain management in individuals with chronic pancreatitis who have undergone the Frey procedure, using a validated pain assessment tool. Additionally, it evaluates exocrine and endocrine insufficiencies along with overall quality of life. Materials and methods: This is a retrospectively analyzed prospective study conducted at KIMS-Sunshine Hospital, Secunderabad. We evaluated 48 patients who underwent the Frey procedure from 2016 to 2021, each with a follow-up period of at least 1 year. The assessment comprised the validated Izbicki pain score along with evaluations of exocrine and endocrine functions, quality of life using the SF-6 questionnaire, and nutritional status, considering factors such as steatorrhea, glycemic control, and weight gain. Results: The total number of patients enrolled was 52. Four patients were identified intraoperatively as having malignancy by frozen section and were therefore converted to the Whipple procedure. Therefore, 48 patients (30 = male, 18 = female, mean age 35.2 years) were analyzed in this study. About 6 patients underwent hepaticojejunostomy along with Frey's procedure in view of benign biliary stricture. In this study of 48 patients, the preoperative mean overall pain score was 66.67. Postoperative mean overall pain scores were recorded at 3, 12, 36, and 60 months, showing values of 6.27, 6.37, 8.26, and 8.42, respectively. These results indicate a clear and statistically significant (p < 0.05) reduction in pain both in the immediate and extended follow-up periods. In the first 3 months following surgery, there was weight gain in most of the patients (65%). Though some patients showed mild weight loss subsequently on long-term follow-up, it was not statistically significant (p-value = 0.041). The SF-36 quality of life questionnaire indicated a general improvement in quality of life for the entire group, largely attributable to a reduction in pain. Preoperatively, the mean physical component score (PCS) and mental component score (MCS) were 25.37 ± 6.67 and 26.28 ± 9.94, respectively. These scores increased to 57.78 ± 15.56 and 48.30 ± 26.82 at 3 years, with a p-value of < 0.05. Conclusion: Frey's procedure is safe and effective in relieving pain in chronic calcific pancreatitis (CCP) with improved quality of life and seems to be better than PD stenting. However, it has no role in the control of exocrine and endocrine pancreatic insufficiency.

Background and objective: Obstructive jaundice (OJ) and acute cholangitis (AC) are common presentations of biliary obstruction. In Eastern India, data regarding the causes of OJ and AC are scarce. This study aimed to determine the etiological spectrum of OJ and AC in a tertiary center in Eastern India. Materials and methods: The data of consecutive patients admitted to the Department of Gastroenterology from January 2021 to December 2023 with a diagnosis of OJ with or without AC was collected from the hospital's computerized database. The data were analyzed for different etiologies of OJ and AC. The results were compared with the various etiologies of OJ reported in previous publications from different centers across India. Results: Totally 772 patients were admitted during this period with a diagnosis of OJ with or without AC. There were 368 male and 404 female patients with a male-to-female ratio of 0.91. In 454 (58.8%) and 309 (41.2%) cases, the etiology of OJ was benign biliary obstruction (BBO) and malignant biliary obstruction (MBO), respectively. The etiologies of BBO-associated OJ were choledocholithiasis (51%) and distal biliary stricture (9%). The causes of MBO-associated OJ were gallbladder cancer (GBC) (21%), periampullary malignancy (10.2%), cholangiocarcinoma (CCA) (5.3%), and carcinoma head of the pancreas (3.4%). Acute cholangitis was observed in 203 (26.2%) with OJ; 23% and 10% of cases of BBO-associated OJ and MBO-associated OJ had AC, respectively. BBOs that presented with AC were choledocholithiasis (50.24%) and distal biliary stricture (14.77%). Similarly, MBOs that presented with AC were GBC (16.74%), periampullary malignancy (10.34%), CCA (6.4%), and carcinoma head of the pancreas (0.0098%). Conclusion: Among the etiologies of AC and OJ, BBOs were more common than MBOs. The most common cause of OJ was choledocholithiasis. Gallbladder cancer was the second most common cause of OJ and the most common cause of malignancy-associated OJ. The most common benign and malignant etiologies of AC were choledocholithiasis and GBC, respectively.

Introduction: Thick-walled gallbladder (TWGB) is a common yet non-specific radiological finding associated with a wide range of gallbladder pathologies, including acute and chronic inflammation, infection, and malignancy. Among the inflammatory causes, xanthogranulomatous cholecystitis (XGC) is a rare but significant condition that often mimics gallbladder carcinoma. This paper presents a pragmatic approach to the diagnosis and management of TWGB, focusing on the complexities posed by XGC. Detailed analysis of imaging techniques, surgical strategies, and histopathological findings is provided to guide clinical decision-making. Objective: This paper presents a pragmatic approach to the diagnosis and management of TWGB, with a particular focus on the complexities posed by XGC mimicking a gallbladder mass in operated patients of TWGB in a tertiary care center over 2 years. Detailed analysis of imaging techniques, surgical strategies, and histopathological findings is provided to guide clinical decision-making. Study design: We had 18 patients of TWGB, 14 males (77.7%) and 4 females (22.2%) who were a part of the prospective study. All cases underwent anticipatory extended cholecystectomy (AEC) with frozen section assessment during the period of 2 years. All these cases were evaluated with ultrasound, triple-phase CT followed by MR/MRCP, and CA 19-9 levels as outlined in the flowchart. Results: In this study out of 18 patients who underwent AEC the frozen section of 15 cases of patients was reported as XGC, and 3 cases were reported as carcinoma GB with T1b stage and these 3 cases further underwent EC in the same setting. Out of 18 cases, 16 had an uneventful postop period and 2 cases developed complications Bile leak which was managed by pigtail drainage and bleeding managed by blood transfusions (Clavien-Dindo Classification-Grade III). Conclusion: All TWGB are not carcinoma GB. Xanthogranulomatous cholecystitis is an important differential diagnosis for TWGB and, therefore, XGC should be considered in the differential diagnosis of TWGB.

Background: Fat accumulation in the liver is affecting 38% of the global population. It can also occur in normal-weight individuals, termed lean non-alcoholic fatty liver disease (NAFLD). This study examines Asian and Western body mass index (BMI) criteria, as well as metabolic dysfunction-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) diagnostic guidelines, in lean fatty liver cases within a healthcare setting. Materials and methods: This study was cross-sectional included 111 lean patients diagnosed with NAFLD using either ultrasound or VCTE from January 2023 to March 2024. Anthropometric, laboratory and non-invasive liver fibrosis evaluation parameters were used. The study assessed clinical characteristics and metabolic risk factors of patients with BMI ≤ 23 kg/m² and BMI between 23 and ≤ 25 kg/m² using MASLD and MAFLD diagnostic criteria. Results: The cohort included NAFLD patients with a mean age of 43.3 years (±13.2 years). Of the participants, 33% were diagnosed through ultrasonography, whereas 67% diagnosis were made via Fibro scan. Majority were male 92 (83%), while females were 19 (17%) of the entire group. The lean NAFLD criteria for Asia and the West were satisfied by 43 (39%) persons with a BMI ≤ 23 kg/m² and 68 (61%) individuals with a BMI between 23 and ≤ 25 kg/m², respectively. The average body mass index (BMI) was 23.0 ± 1.5 kg/m². Diabetes was observed in 16%, hypertension 11%, and ischemic heart disease in 2%. Out of the total individuals, 92 satisfied the MASLD-MAFLD criteria, whereas 18 did not qualify the MAFLD criteria for diagnosis and were classed as MASLD-Alone. Elevated triglycerides, insulin resistance (HOMA-IR ≥ 2), and three or more cardiometabolic risk factors (CMRF) were significant in the MASLD-MAFLD group compared to the MASLD-Alone group (p < 0.05). Comparing BMI criteria, no significant differences were found in terms of fibrosis between the Western and Asian lean NAFLD BMI criteria's (p = 0.243). Conclusion: Lean NAFLD is a major global health concern. Applying non-Asian BMI criteria (BMI ≤ 25 kg/m²) for lean Asians improves early detection and intervention for at-risk individuals. Accurate use of MAFLD and MASLD criteria is essential to prevent confusion in diagnosing lean NAFLD. Further multicenter investigations with larger sample numbers are required to corroborate these results in our community.

Aim and background: As rectal cancer diagnosis becomes more prevalent due to the increased awareness caused by campaigns, this study aims to focus on the demographics of patients diagnosed with rectal cancer in the Kingdom of Bahrain Methods: A retrospective cross-sectional study design was conducted on 184 patients diagnosed with primary or second primary rectal cancer. Stage and site of tumor at diagnosis, gender, BMI, family history, histology, and metastasis are discussed throughout the paper. Results: The majority of the population (85.9%) were Bahraini, with males (57.6%) being more prevalent. A little over 50% of patients diagnosed with rectal cancer were aged 60 years or younger. In most cases, the tumors were spotted in the lower rectum (48.9%) and were diagnosed by the appearance of symptoms (91.8%). Kaplan–Meier Survival analysis showed that the overall survival for males is 95.3% and for females 93.6% for 1 year. Conclusion: The high number of Bahraini males diagnosed with rectal cancer highlights the importance of early screening and detection. The prevalence of the tumor in the lower rectum suggests the need for improved education on recognizing symptoms and seeking medical attention. Further research is required to establish a comprehensive national screening program for rectal cancer in Bahrain. Clinical Significance: Understanding the demographic and clinical characteristics of rectal cancer patients in the Kingdom of Bahrain is required to target early screening and public awareness. The findings of this study provide a solid foundation for future developments in rectal cancer diagnosis and treatment to improve survival outcomes.

Background: Enhanced recovery after surgery (ERAS) protocols advocate for early enteral feeding to prevent postoperative ileus. Chewing gum acts as a type of sham feeding that triggers the cephalic phase of digestion by stimulating the cephalic vagus nerve. This can enhance gastrointestinal motility and may lead to quicker recovery of gas and bowel movements. Objectives: To assess how chewing gum during the early postoperative phase affects the duration of postoperative ileus in terms of time to appreciation of first flatus, time to passage of first stools, and duration of hospital stay. Materials and methods: The study was conducted in our division of colorectal surgery. This is a case-control study carried out over three years (2020–2023). A total of 100 patients were included, the first 50 were allocated to the control group, and another 50 were allocated to the chewing gum group. All patients above the age of 14 years who underwent resection for colorectal cancers were included. Results: The average age in the control group was 51.44 years and that in the chewing gum group was 50.04 years. The average duration of surgery for the control group was 156.3 minutes (2.6 hours) and 163.8 minutes (2.7 hours) in the chewing gum group. The average time of passage of the first flatus in the chewing gum group was 51.28 hours compared to 66.26 hours in the control group (p = 0.0002). The average time to first bowel movement in the chewing gum group was 71.42 hours. In comparison, the time to first bowel movement in the control group was 85.78 hours (p = 0.000011). The average hospital stay in the chewing gum group was 6.3 days and that in the control group was 6.4 days (p = 0.274254). Conclusion: Chewing gum as a means of sham feeding is a cost-friendly method that significantly decreases the postoperative ileus but has no effect on postoperative hospital stay.

Chronic Hepatitis B (CHB) remains a major public health problem, leading to various complications such as liver fibrosis, cirrhosis, and hepatocellular carcinoma. The existing diagnostic markers for Hepatitis B virus (HBV) are limited in distinguishing different CHB phases and intra-hepatic viral replication activity. In the past few years, several non-invasive potential blood markers that reflect viral intra-hepatic replicative state more accurately have been in progress and are gaining importance. Despite substantial efforts, the clinical utility of these new markers in CHB management is limited and unexplored. Therefore, in this review, we will discuss some of the newer HBV markers, their potential role in the diagnosis and monitoring of CHB patients.

The immune system plays a central role in controlling acute hepatitis B infection and in patients resolving chronic hepatitis B (CHB). Given that 221 million (75%) of CHB patients reside in low- and middle-income countries, the development of a vaccine with therapeutic properties represents a rational and cost-effective approach more than a romantic endeavor. This review systematically analyzes the key variables related to the safety, efficacy, and effectiveness of CHB treatments. HeberNasvac experience is revisited for addressing the challenges and potentialities of therapeutic vaccines, as well as the current roadblocks in research and development, registration, and large-scale implementation.

Background: Colorectal metastasis from primary breast cancer is rare and presents a challenge for diagnosis and treatment. Aim: To report two cases of colorectal metastasis from a primary invasive lobular breast carcinoma (ILBC) with different presentations while discussing the mode of diagnosis, immunohistochemistry (IHC), course of treatment, and response. Case descriptions: Case 1: A 47-year-old female, with a known case of bilateral invasive lobular breast cancer, was diagnosed in 2015 and staged as p Tx N3 M0. She underwent a bilateral nipple-sparing mastectomy and presented 8 years later with complaints of left-sided abdominal pain and altered bowel habits for 2 months. She underwent a colonoscopy, and an erythematous area was noted in the ascending colon, and narrowings were seen in the transverse and rectosigmoid junction. Histopathological findings were consistent with metastatic ILBC with the same IHC pattern. Case 2: A 52-year-old woman presented in September 2019 with a 1-month history of constipation, generalized colicky abdominal pain, 7 kg weight loss, nausea, and anorexia. She underwent a colonoscopy, which revealed a malignant-appearing apple-core lesion at the proximal rectum with severe stenosis that could not be bypassed. A PET-CT showed suspicious breast lesions, and after further investigations and biopsies, she was diagnosed with primary invasive lobular carcinoma (ILC) of the breast with rectal metastasis. Clinical significance: With the increasing incidence of both colorectal and breast cancer and the rarity of breast cancer metastasis to the gastrointestinal tract (GIT), this case series aims to highlight the growing incidence of lobular breast cancer metastasis to the colon and to shed light on the importance of further research in this area in terms of early detection and treatment to improve the prognosis of such patients. Conclusion: This case series highlights the clinical presentations, diagnosis, histopathology, challenges, and trials of treatment in our patients. These findings show the importance of considering gastrointestinal (GI) involvement in breast cancer patients and the need for multidisciplinary approaches to achieve better outcomes. However, this is an area of need for more research and awareness to improve the understanding and management of GI metastases from breast cancer.

Esophageal leiomyomas (EL) are the most common benign tumors of the esophagus, being pedunculated polyp presentation is very rare. A 65-year-old female presented with symptoms of troublesome dysphagia. Esophagogastroduodenoscopy (EGD) performed revealed a pedunculated polyp of ~ 3 × 1.7 × 1.5 cm in size covered by normal-looking mucosa. The polypoid lesion was then removed successfully with a hot polypectomy snare. The histopathological diagnosis of the polyp turned out to be leiomyoma. Patient symptoms were relieved after successful removal.

Bevacizumab and atezolizumab combination is one of the preferred combinations for managing advanced hepatocellular carcinoma (HCC), while the evidence on monotherapy with either agent is not convincing. We present a case of a man in his 50s diagnosed with HCC with spinal metastases who showed a good response to combination therapy. However, he developed severe proteinuria and hypertension secondary to bevacizumab, which had to be discontinued after 18 cycles. After an informed decision, atezolizumab was continued and the patient showed a sustained response. Till date, he has received 16 additional cycles of atezolizumab monotherapy after discontinuation of bevacizumab and continues to show a persistent response, with a progression-free survival of over 30 months now. It needs to be prospectively evaluated if atezolizumab's effectiveness as monotherapy for extended periods, as in our report, is a residual effect of initial combination therapy or if HCC is intrinsically responsive to immunotherapy alone.

Background and aim: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Most patients are diagnosed at an advanced stage, limiting their treatment options. The traditional assessment of liver function using the Child–Pugh score has limitations due to its subjectivity. The albumin-bilirubin (ALBI) grade delivers a more precise evaluation of liver function. This study examines overall survival (OS) in advanced HCC patients treated with first-line systemic therapy and the impact of ALBI grading on these outcomes. Materials and methods: A total of 104 patients with advanced HCC treated between January 2017 and December 2023 with one of the three first-line therapy options: Sorafenib, lenvatinib or atezolizumab/bevacizumab were retrospectively analyzed. The Kaplan–Meier method was utilized to examine the survival results, and the log-rank test was employed to evaluate the variations in survival among ALBI grades and therapy types. Cox proportional hazards regression examined the impact of ALBI grading and other covariates on OS, with a significance threshold of p < 0.05 for the multivariable model. Results: The median age of HCC patients was 58.5 years, with 70% males, and a primary etiology of hepatitis C (43%). The median OS and time to progression (TTP) in this cohort were 9 months and 3.25 months. In ALBI grade I patients, the OS was 21 months, while in grade II or III patients, it was just 5 months. Treatment-related side effects necessitated dose reductions in over 84% of patients. Albumin-bilirubin grade, Child–Pugh class, and treatment modifications due to adverse effects were significant predictors of survival. Conclusion: Lenvatinib appears to have better survival outcomes compared to other options. The albumin-bilirubin grading is a useful method for evaluating liver function and forecasting survival rates for individuals with HCC. Clinical significance: Our findings support the use of ALBI grading in clinical decision-making for advanced HCC.